No panic, please - we're divers!

Appeared in DIVER December 2013

Your stomach is churning and you feel sick. You sweat, your skin changes colour, your breath becomes faster and shallower and your vision is restricted. Panic attacks are worse under water, but the good news is that they are preventable. Doctors ANDREAS ACERANT and SIMONETTA VERNOCCHI explain

EXPERIENCING ANXIETY, even if only for a short period of time, is never pleasant. This is even more the case when anxiety is accompanied by its evil brother, panic, and still more so when it is experienced not on land, but under water. The reason why healthy subjects without a personal or family history of anxiety or panic suddenly suffer from panic attacks under water remains unknown. However, it is important to try to understand its mechanisms. Panic, although harmless in itself, may be the most common cause of accidents among divers. As James Jones wrote in his novel Go to the Widowmaker: “The panic was the greatest danger, the enemy, the only danger that there was in diving.”Although outside the scope of fiction, Arthur Bachrach and Glen Egstrom, the experts in panic in diving and authors of the essay Stress and Performance in Diving, agree: “Most of us in diving research believe that panic is the overwhelming cause of the majority of injuries and fatalities in diving,” they say.Any experienced divemaster or instructor can confirm these statements. That should not, however, lead us to think of panic as an ever-lurking enemy, ready to strike anyone regardless of age, experience, sex or breed. Although dangerous, panic is usually preventable.

A STUDY IN 2000 by David &Lynn Colvard examined more than 12,000 divers who had experienced panic, in an attempt to learn what had caused this. The results were surprising. Respondents were offered a list of 43 possible causes of panic, such as “sharks”, “darkness”, “air hunger” and so on. The options were divided into three categories, relating to diving conditions, equipment problems, physical and/or psychological problems. The divers were asked to assess which of these threats had been present during the panic attacks. Among all 43 possible threats, the three boxes most selected in each category were the last ones: “Other”. In short, the events triggering the panic reactions were not the obvious ones. In most cases, the triggering reason was something trivial or routine, something that no one would see as a reason to cause panic at another time. Reading DAN’s annual reports on accidents and fatalities in diving, it is evident that an astonishing number of dives could have been concluded easily if the diver had followed the fundamentals of basic training. Just think of the rule: “Do not hold your breath and do not go up too fast”. How many times have we read, studied, taught or practised it, thinking that we would never commit such a basic error Yet anyone can panic. A panic attack is as involuntary as a heart attack.The panic is not cowardice, or lack of courage, but an involuntary reaction to a massive secretion of adrenaline into the bloodstream. This comes by order of the sympathetic nervous system which, facing what it perceives as a huge threat, causes the heart rate, body temperature and blood sugar quickly and dramatically to rise. “Butterflies” start flying in your stomach, or a sense of nausea appears. You start sweating. Your skin becomes red or pale. Your breath becomes faster, less deep and dyspnoeic (or irregular). You experience the phenomenon known as “perceptual narrowing”, during which peripheral vision can be lost, achieving an effect similar to looking at the world through a tube.The worst thing is that you feel more and more agitated, and are unable to think clearly. It follows that your attention becomes focused on the problem, so that the right solution for that situation seems to fade away and no longer exists. With a real panic attack in progress, there is very little that the rational part of the brain can do to stop it quickly. The body takes several minutes to absorb the adrenalin, and the risk of taking the wrong actions increases.

THE GOOD NEWS IS that despite the mystery that surrounds it, panic can almost always be prevented. This is underlined by a clue, at first sight insignificant, in the above-mentioned study. Although the results provided by divers on the plausible causes of their panic attacks seemed unrelated, and apparently so scattered that it was impossible to draw a logical, statistical or epidemiological conclusion, all tended to agree that they had started to hyperventilate just before the panic attack began. It is worth mentioning that hyperventilation (rapid breathing, shallow, irregular) is a classic sign of anxiety. Anxiety is an accumulation of daily stress that goes as far as the generation point of an unconscious fear of not being able to solve problems. From this arises a feeling of powerlessness that amplifies the uncertainty, worry, fatigue, frustration and fear that are still part of everyday life. It is therefore likely that this is what happens to the diver who, like most of us, is stressed even before entering the water. There may be memories of a difficult or frightening dive, and the diver is concerned about this. Perhaps the diving conditions are unusually difficult. Or maybe he went to bed late the night before, found traffic in the morning and had to run to catch the dive-boat. Perhaps he can’t get that damn office problem out of his head. Or the instructor is getting him nervous, taunting or insulting him. Or the students are particularly unruly and refuse to follow directives. As he enters the water, the diver is troubled, angry, less able to react in a consistent and ready way – so he can easily be the object of fear. Breathing is more difficult than normal, he uses the BC more than usual, and when the unexpected happens, even something harmless in itself (like the mask that comes off or the fin that remains entangled) he begins to hyperventilate – only the air never seems sufficient. The feeling of “air hunger” and the risk of suffocation increases. Panic is at hand.

OF COURSE, WE SHOULDN’T assume that all divers who get stuck in morning traffic will have a panic attack. Human beings deal with stress and everyday worries in different ways. Some are more vulnerable than others to stress, and are therefore more vulnerable to panic. Yet no one is immune to it, because our individual threshold of panic may also change from day to day.Although it may seem scary, be reassured that a panic attack rarely occurs out of nowhere during a dive. In most cases, stress has been working for hours and sometimes even days. In the end the straw breaks the camel’s back and the diver feels overwhelmed – the fear of failure triggers panic. Think of a juggler with three plates in the air, then four, then five. Finally, one additional element proves too many, and the exhibition ends with an explosion of chinaware. The cause of loss of control is not the sixth plate in itself, but simply having too many plates in the air. Similarly, anything can trigger panic and cause loss of control, but this can easily be prevented “by removing some plates”, or reducing stress and psychological pressure when we are under water, and refusing to take care of all unnecessary burdens and responsibilities.One of the best ways to reduce and avoid stress is to establish a series of breaks in the day of the dive: rest, focus on the situation and think about what you are going to do next. If you are stressed when you reach the meeting point, once parked, possibly before moving the equipment, take a break for a minute or two and relax. When the equipment is on board, but before you get kitted up, take a break. When you are in the water, but before you dive, break. And so on throughout the dive. There are at least three good reasons why frequent breaks reduce stress and help to prevent panic. Firstly, regular breaks reduce fatigue. Rest promotes the lowering of the level of adrenaline, the slowing of the heartbeat, a slower and deeper breathing, and the level of carbon dioxide in solution in blood turns to normal. In hyperventilation phase, CO2 decreases (saturation of O2 increases), and normal breathing helps to restore natural conditions. This, however, is a point that is still debated.Secondly, the breaks are a chance to enjoy a moment of mental rest and, without stress, to slow the rush of the events with which we are obliged to keep up, paying more attention to new needs that arise. Finally, frequent breaks are an opportunity to think about the next task and how to do it.

BEFORE KITTING UP, take a break and mentally organise the steps to follow, one after the other. Scroll through that mental list of requirements. Try to visualise the problems that can occur and their solutions. The psychology of sport has proved that visualisation is a powerful weapon against anxiety, stress and panic. Breaks may also provide an opportunity to keep your breathing under control. Breathing with the chest wall, and not with diaphragm, is an intensive energy action, because we use the wrong muscles. Breathing with the diaphragm is the natural way of breathing. It induces a state of relaxation and is fundamental to keeping breathing under control. As we have seen, hyperventilation is a well-known cause of anxiety and panic. When you don’t feel good, it’s best not to dive. When you have a feeling of nausea and just don’t want to dive for some reason you cannot identify, it is better not to. Don’t let peer pressure push you beyond your limits, because you would begin your dive already stressed and more susceptible to panic. If anyone fails to understand your predicament and insists on making you feel embarrassed, invoking a sudden ear pain that will make you unable to equalise always makes for a great escape!